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Risk Identification, Assessment and Control (RIAC) Intake Form

Emergency Notice

To report an emergency, fatality, or imminent life threatening situation please call 911

Agency Name

NOTE: In order for the Office of Risk Management (ORM) to fully process your complaint, complete and accurate information about the worksite is necessary.

Site Address

Site Location

Management Official

Telephone Number

Describe the nature of the risk or hazard.

Include information about potential risks to the District, the cost implications, if any, and the approximate number of employees exposed to or threatened by each risk or hazard. Include also how the risk or hazard can be mitigated, or if there are controls in place to address your concerns.

Specify the particular building or worksite where the alleged risk or hazard exists.

Please describe the type of threat or risks that may be faced by the government. Please check all that apply.

Please indicate what you believe the severity​ of the risk or hazard is.

Imminent Danger: Conditions or practices exist in any place of employment which could reasonably be expected to cause death or serious physical harm immediately or before the imminence of such danger can be eliminated through the enforcement procedure. (Typical abatement period: Immediate)

Minimal Severity: Although such violations reflect conditions which have a direct and immediate relationship to the safety and health of employees, the injury or illness most likely to result would probably not cause death or serious physical harm. (Typical abatement period 120 days)

Imminent Danger

High Severity

Medium Severity

Low Severity

Minimal Severity

This condition has been brought to the attention of: (Choose all that apply)

Employer

Other Government Agency (specify below)

other government agency

I am a(n):

Employee

Agency Risk Management Representative (ARMR)

Representative of Employees

Other (specify below)

Complainants have the right to request that their names not be revealed to their employer. Providing your name and address, will only allow ORM staff to communicate with you regarding your complaint.

Please indicate your preference:

Do NOT reveal my name

My name may be revealed

Complainant Name

Complainant Telephone Number

Complainant Mailing Adddress

Complainant Email Address

If you are an authorized representative of employees affected by this complaint, please state the name of the organization that you represent and your title.

Organization Name

Your Title

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